髌骨肿瘤与瘤样病变的诊断和治疗
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摘要
目的探讨髌骨肿瘤与瘤样病变的临床、影像和病理学特点及其治疗方法和结果。方法回顾性分析北京积水潭医院1999年6月至2017年12月收治的髌骨肿瘤及瘤样病变53例,采集并统计患者的年龄、性别、侧别、临床症状及其持续时间。影像学检查以X线片和增强CT为主,分析其影像学特点包括累及范围、骨破坏形式、骨基质情况、边界、骨皮质改变以及是否病理骨折、累及关节等。最终诊断以病理学检查结果为准,其中良性肿瘤39例、瘤样病变11例、恶性肿瘤3例。外科治疗分为刮除和切除,其中46例良性肿瘤和瘤样病变行刮除手术,44例同时行植骨术(自体骨、异体骨、人工骨),4例Campanacci 3级骨巨细胞瘤和3例恶性肿瘤行髌骨切除术。术后评价膝关节功能包括膝关节活动度和MSTS评分。结果平均随访时间为39.6(3~156)个月,刮除病例术后植骨均可愈合,1例骨巨细胞瘤局部复发,1例软骨母细胞瘤术后伤口不愈合。术后功能评价刮除病例的膝关节活动度绝大多数可恢复至术前状态、MSTS评分平均为29分,而切除病例的膝关节活动度可接受且可完全伸直、MSTS评分平均为27.8分。结论髌骨的肿瘤和瘤样病变发生率很低,多见于30岁左右的年轻人群,男多于女,多以膝前部疼痛为首发症状,临床和影像学表现往往不具备特异性,需要病理学确定诊断。病理类型多种多样,良性肿瘤和瘤样病变明显多于恶性肿瘤,良性肿瘤中又以软骨母细胞瘤和骨巨细胞瘤最为常见。Enneking 1、2期良性肿瘤或瘤样病变的最常用治疗方法为单纯刮除或扩大刮除、植骨术,术后膝关节功能很好。Enneking 3期、尤其是Campanacci 3级的骨巨细胞瘤以及恶性肿瘤的最适宜的手术方式是髌骨切除术,术后可重建或不重建伸膝装置,均可获得可接受的膝关节功能。
Objective To report the clinical, radiographic and pathologic characteristics and treatment outcomes of patellar tumors and tumor-like lesions. Methods Between September 1999 and December 2017, 53 patients of patellar tumors and tumor-like lesions were analyzed retrospectively by the age, gender, side, clinical symptom and duration. The imaging characteristics were based mainly on radiographs and enhanced CT scans including bone destruction extend, pattern, matrix, border, cortex and pathological fracture, joint involvement. The final diagnosis was confirmed by the results of pathological examination. There were 39 benign tumors, 11 tumorlike lesions and 3 malignant tumors. The determined treatment included curettage with or without bone graft for 46 benign tumors and tumor-like lesions, and patellectomy for 4 Campanacci Grade III giant cell tumors and 3 malignant tumors. The functional assessment included range of motion( ROM) of the knee joint and the Musculoskeletal Tumor Society( MSTS) score. Results The average follow-up was 39.6 months( range: 3-156 months). All curettage cases with bone graft were healed as wish. One local recurrence of giant cell tumors, one wound nonunion of chondroblastoma were observed. The functional assessment results were extremely good for curettage cases with the average MSTS score of 29, whereas the ROM of the knee joint was acceptable for patellectomy cases with the average MSTS score of 27.8. Conclusions Patellar tumors and tumor-like lesions are rare and usually occur in young adults around 30 years old with male preponderance. Anterior knee pain is the most common primary symptom. Clinical and imaging findings are not so specific that the final diagnosis is always determined by histological findings. The diagnosis varies from benign to malignant tumors with great advantage of benign tumors and tumor-like lesions, and chondroblastomas and giant cell tumors are the most common benign tumors as well. For patients with Enneking Stage 1 or 2 benign tumors, only curettage or extended curettage with or without bone graft is indicated. The postoperative functions of the knee joint are excellent. But for patients with Enneking Stage 3 benign tumors( especially Campanacci grade 3 GCT) and malignant tumors, patellectomy with marginal or wide margin is needed. With or without extensor mechanism reconstruction, postoperative functions of the knee joint are acceptable or even good.
Objective To report the clinical, radiographic and pathologic characteristics and treatment outcomes of patellar tumors and tumor-like lesions. Methods Between September 1999 and December 2017, 53 patients of patellar tumors and tumor-like lesions were analyzed retrospectively by the age, gender, side, clinical symptom and duration. The imaging characteristics were based mainly on radiographs and enhanced CT scans including bone destruction extend, pattern, matrix, border, cortex and pathological fracture, joint involvement. The final diagnosis was confirmed by the results of pathological examination. There were 39 benign tumors, 11 tumorlike lesions and 3 malignant tumors. The determined treatment included curettage with or without bone graft for 46 benign tumors and tumor-like lesions, and patellectomy for 4 Campanacci Grade III giant cell tumors and 3 malignant tumors. The functional assessment included range of motion( ROM) of the knee joint and the Musculoskeletal Tumor Society( MSTS) score. Results The average follow-up was 39.6 months( range: 3-156 months). All curettage cases with bone graft were healed as wish. One local recurrence of giant cell tumors, one wound nonunion of chondroblastoma were observed. The functional assessment results were extremely good for curettage cases with the average MSTS score of 29, whereas the ROM of the knee joint was acceptable for patellectomy cases with the average MSTS score of 27.8. Conclusions Patellar tumors and tumor-like lesions are rare and usually occur in young adults around 30 years old with male preponderance. Anterior knee pain is the most common primary symptom. Clinical and imaging findings are not so specific that the final diagnosis is always determined by histological findings. The diagnosis varies from benign to malignant tumors with great advantage of benign tumors and tumor-like lesions, and chondroblastomas and giant cell tumors are the most common benign tumors as well. For patients with Enneking Stage 1 or 2 benign tumors, only curettage or extended curettage with or without bone graft is indicated. The postoperative functions of the knee joint are excellent. But for patients with Enneking Stage 3 benign tumors( especially Campanacci grade 3 GCT) and malignant tumors, patellectomy with marginal or wide margin is needed. With or without extensor mechanism reconstruction, postoperative functions of the knee joint are acceptable or even good.
引文
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[3]Cole WH.Primary tumors of the patella[J].J Bone Joint Surg1925,23:637-654.
[4]Dahlin DC.Tumors of the patella[J].JAMA,1968,206(3):650.
[5]Kransdorf MJ,Moser RP Jr,Vinh TN,et al.Primary tumors of the patella.A review of 42 cases[J].Skeletal Radiol,1989,18(5):365-371.
[6]Mercuri M,Casadei R.Patellar tumors[J].Clin Orthop Relat,2001,(389):35-46.
[7]Ferguson PC,Griffin AM,Bell RS.Primary patellar tumors[J].Clin Orthop Relat Res,1997,(336):199-204.
[8]Singh J,James SL,Kroon HM,et al.Tumour and tumour-like lesions of the patella-a multicentre experience[J].Eur Radiol,2009,19:701-712.
[9]Casadei R,Kreshak J,Rinaldi R,et al.Imaging tumors of the patella[J].Eur J Radiol,2013.82(12):2140-2148.
[10]刘子君,李瑞宗,刘昌茂,等.骨肿瘤及瘤样病变12,404例病理统计分析[J].中华骨科杂志,1986,6(3):162-169.
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[13]覃康,朱斌,李世杰,等.髌骨肿瘤外科治疗[J].国际骨科学杂志,2017,38(2):129-133.
[14]Xu H,Nugent D,Monforte HL,et al.Chondroblastoma of bone in the extremities a multicenter retrospective study[J].J Bone Joint Surg Am,2015,97(11):925-931.
[15]Niu X,Zhang Q,Hao L,et al.Giant cell tumor of the extremity:retrospective analysis of 621 Chinese patients from one institution[J].J Bone Joint Surg Am,2012,94(5):461-467.
[16]Ma K,Zhao HT,Niu XH,Osteoid osteoma of the patella report of two cases[J].Chin Med J(Engl),2011,124(23):4096-4098.
[17]De Coster E,Van Tiggelen R,Shahabpour M,et al.Osteoblastoma of the patella.Case report and review of the literature[J].Clin Orthop Relat Res,1989,(243):216-219.
[18]Kaymaz B,Eroglu M,Kaymaz N,et al.An uncommon cause of anterior knee pain:patellar chondroma[J].J Pediatr Hematol Oncol,2014,36(1):81-82.
[19]Chaudhary D,Bhatia N,Ahmed A,et al.Unicameral bone cyst of the patella[J].Orthopedics,2000,23(12):1285-1286.
[20]Traore A,Doukoure B,Sie Essoh JB,et al.Primary aneurysmal bone cyst of the patella:a case report[J].Orthop Traumatol Surg Res,2011,97(2):221-224.
[21]Hopper G,Gupta S,Bethapudi S,et al.Tophaceous gout of the patella:a report of two cases[J].Case Rep Rheumatol,2012;2012:253693.
[22]Tam W,Resnick D,Haghighi P,et al.Intraosseous ganglion of the patella[J].Skeletal Radiol,1996,25(6):588-591.
[23]Nagai S,Okuda N,Azuma H,et al.Osteosarcoma of the patella.A case report[J].Clin Orthop Relat Res,1993,(289):243-246.
[24]Kumagai K,Abe K,Tomita M,et al.Chondrosarcoma of the patella[J].J Orthop Sci,2008,13(6):556-560.
[25]Gorelik N,Dickson BC,Wunder JS,et al.Ewing's sarcoma of the patella[J].Skeletal Radiol,2013,42(5):729-733.
[26]Lebon D,Saidi L,Merlusca L,et al.Patella plasmacytoma:an unusual localization[J].Am J Hematol,2011.86(6):504.
[27]Cha S,Schultz E,McHeffey-Atkinson B,et al.Malignant lymphoma involving the patella[J].Skeletal Radiol,1996,25(8):783-785.
[28]Halanski MA,Torga-Spak R,Teitge RA.Osteoarthritic cyst mimicking patellar osteonecrosis[J].J Knee Surg,2004,17(1):30-32.
[29]Gil-Albarova J,G6mez-Palacio VE,Herrera A.Hematogenous osteomyelitis of the patella[J].J Pediatr Orthop B,2012,21(5):411-414.
[30]Dhillon MS,Rao SS,Sandhu MS,et al.Tuberculosis of the patella[J].Skeletal Radiol,1998,27(1):40-42.
[31]Song M,Zhang Z,Wu Y,et al.Primary tumors of the patella[J].World J Surg Oncol,2015,13:163.
[2]Enneking WF,Dunham W,Gebhardt MC,et al.A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system[J].Clin Orthop Relat Res,1993,(286):241-246.
[3]Cole WH.Primary tumors of the patella[J].J Bone Joint Surg1925,23:637-654.
[4]Dahlin DC.Tumors of the patella[J].JAMA,1968,206(3):650.
[5]Kransdorf MJ,Moser RP Jr,Vinh TN,et al.Primary tumors of the patella.A review of 42 cases[J].Skeletal Radiol,1989,18(5):365-371.
[6]Mercuri M,Casadei R.Patellar tumors[J].Clin Orthop Relat,2001,(389):35-46.
[7]Ferguson PC,Griffin AM,Bell RS.Primary patellar tumors[J].Clin Orthop Relat Res,1997,(336):199-204.
[8]Singh J,James SL,Kroon HM,et al.Tumour and tumour-like lesions of the patella-a multicentre experience[J].Eur Radiol,2009,19:701-712.
[9]Casadei R,Kreshak J,Rinaldi R,et al.Imaging tumors of the patella[J].Eur J Radiol,2013.82(12):2140-2148.
[10]刘子君,李瑞宗,刘昌茂,等.骨肿瘤及瘤样病变12,404例病理统计分析[J].中华骨科杂志,1986,6(3):162-169.
[11]高石军,陈百成,陈会军,等.髌骨肿瘤的诊断与治疗[J].中骨国骨肿瘤骨病,2003,2(3):144-146.
[12]刁胜林,吴文娟,张泽坤,等.髌骨骨肿瘤及肿瘤样病变分析[J].临床放射学杂志,2010,29(9):1219-1223.
[13]覃康,朱斌,李世杰,等.髌骨肿瘤外科治疗[J].国际骨科学杂志,2017,38(2):129-133.
[14]Xu H,Nugent D,Monforte HL,et al.Chondroblastoma of bone in the extremities a multicenter retrospective study[J].J Bone Joint Surg Am,2015,97(11):925-931.
[15]Niu X,Zhang Q,Hao L,et al.Giant cell tumor of the extremity:retrospective analysis of 621 Chinese patients from one institution[J].J Bone Joint Surg Am,2012,94(5):461-467.
[16]Ma K,Zhao HT,Niu XH,Osteoid osteoma of the patella report of two cases[J].Chin Med J(Engl),2011,124(23):4096-4098.
[17]De Coster E,Van Tiggelen R,Shahabpour M,et al.Osteoblastoma of the patella.Case report and review of the literature[J].Clin Orthop Relat Res,1989,(243):216-219.
[18]Kaymaz B,Eroglu M,Kaymaz N,et al.An uncommon cause of anterior knee pain:patellar chondroma[J].J Pediatr Hematol Oncol,2014,36(1):81-82.
[19]Chaudhary D,Bhatia N,Ahmed A,et al.Unicameral bone cyst of the patella[J].Orthopedics,2000,23(12):1285-1286.
[20]Traore A,Doukoure B,Sie Essoh JB,et al.Primary aneurysmal bone cyst of the patella:a case report[J].Orthop Traumatol Surg Res,2011,97(2):221-224.
[21]Hopper G,Gupta S,Bethapudi S,et al.Tophaceous gout of the patella:a report of two cases[J].Case Rep Rheumatol,2012;2012:253693.
[22]Tam W,Resnick D,Haghighi P,et al.Intraosseous ganglion of the patella[J].Skeletal Radiol,1996,25(6):588-591.
[23]Nagai S,Okuda N,Azuma H,et al.Osteosarcoma of the patella.A case report[J].Clin Orthop Relat Res,1993,(289):243-246.
[24]Kumagai K,Abe K,Tomita M,et al.Chondrosarcoma of the patella[J].J Orthop Sci,2008,13(6):556-560.
[25]Gorelik N,Dickson BC,Wunder JS,et al.Ewing's sarcoma of the patella[J].Skeletal Radiol,2013,42(5):729-733.
[26]Lebon D,Saidi L,Merlusca L,et al.Patella plasmacytoma:an unusual localization[J].Am J Hematol,2011.86(6):504.
[27]Cha S,Schultz E,McHeffey-Atkinson B,et al.Malignant lymphoma involving the patella[J].Skeletal Radiol,1996,25(8):783-785.
[28]Halanski MA,Torga-Spak R,Teitge RA.Osteoarthritic cyst mimicking patellar osteonecrosis[J].J Knee Surg,2004,17(1):30-32.
[29]Gil-Albarova J,G6mez-Palacio VE,Herrera A.Hematogenous osteomyelitis of the patella[J].J Pediatr Orthop B,2012,21(5):411-414.
[30]Dhillon MS,Rao SS,Sandhu MS,et al.Tuberculosis of the patella[J].Skeletal Radiol,1998,27(1):40-42.
[31]Song M,Zhang Z,Wu Y,et al.Primary tumors of the patella[J].World J Surg Oncol,2015,13:163.